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330
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Inguinal Lymphadenectomy, Radical Vulvectomy
ClarissaLam andMarioM.Leitao
31
Background ofLymphedema After
Inguinofemoral Lymphadenectomy
Lower extremity lymphedema (LEL) is a relatively common complication of inguinofemoral
lymphadenectomy (IFL). Rates of LEL after IFL
in patients with melanoma have been reported
between 13% and 55% [1]. Lymphedema can
either be a temporary or a chronic and debilitating condition. In one series of 204 patients with
melanoma, 58 patients underwent IFL and 26%
of patients had measurable LEL six months postoperatively, with 8% of patients having signicant functional decits [104]. In the
GROINSS-V-1 prospective trial, the rate of LEL
was 25.2% after sentinel lymph node (SLN) dissection with lymphadenectomy versus 1.9% after
SLN dissection alone [105].
Vulvectomy and IFL are typically performed
using separate incisions. In one study, approxi-
C. Lam
Gynecology Service, Department of Surgery,
Memorial Sloan Kettering Cancer Center,
New York, NY, USA
e-mail: LamC2@mskcc.org
M. M. Leitao (*)
Gynecology Service, Department of Surgery,
Memorial Sloan Kettering Cancer Center,
New York, NY, USA
Department of Obstetrics and Gynecology, Weill
Cornell Medical College, New York, NY, USA
e-mail: leitaom@mskcc.org
mately three-quarters of patients who underwent
modied radical vulvectomy and inguinal lymphadenectomy with separate incisions had one or
more documented complications, with 28% of
patients experiencing lymphedema [33]. The
next sections will cover methods identied in the
literature to recognize, prevent, and manage
lymphedema.
Recognition ofLymphedema
Following Inguinofemoral
Lymphadenectomy
Radionuclide lymphoscintigraphy is the gold
standard imaging modality for the diagnosis of
lymphedema; it is also useful in surgical planning. Other imaging modalities include magnetic resonance lymphangiography and
indocyanine green lymphangiography. Medical
history and physical examination by qualied
health care practitioners, however, have been
used to accurately diagnose patients in approximately 90% of cases [39]. Secondary lymphedema after lymphadenectomy typically
presents 12 to 18 months after the inciting
injury. Lymphedema almost universally involves
the distal extremity and leads to pitting edema
on examination. Grading and/or staging can be
performed for lymphedema (Table 31.1,
Fig. 31.1). Lymphedema after IFL, however,
can manifest in the upper thigh, vulva, and/or
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_31
333
334
cd
Table 31.1 Grading systems for lymphedema (Dessources et al. 2020)
ISL stage ISL grading CTCAE grade
0: Subclinical impaired lymphatic transport
without lymphedema
1: Relatively high protein edema that
reverses with elevation +/− pitting +/−
increase in proliferating cells
2: High protein edema with dermal brosis
that does not easily reverse with elevation.
Usually no pitting
3: Trophic skin changes: warty overgrowths,
acanthosis, fat deposits, usually without
pitting. Also known as lymphatic
elephantiasis
ISL International Society of Lymphology, CTCAE Common Terminology Criteria for Adverse Events
Mild, <20% increase in
volume
Moderate, 20%–40% increase
in volume
Severe, >40% increase in size Grade 3: Severe symptoms
Grade 1: Trace thickening or faint
skin discoloration
Grade 2: Limits activities of daily
living. Characterized by marked
skin discoloration, leathery
texture, and papillary formation
limiting self-care and activities of
daily living
C. Lam and M. M. Leitao
ab
Mild Stage 1
Moderate Stage 1Moderate Stage 2Severe Stage 3
Fig. 31.1 International Society of Lymphology stages/
grade of lymphedema. (a) Stage 1 mild lymphedema with
40% limb difference, and abnormal fat deposits; (b)
Stage 1 moderate lymphedema with a 20%–40% difference in limb size; (c) Stage 2 moderate lymphedema with
mons pubis. The Stemmer sign, or the inability
to pinch up the skin on the dorsum of the foot, is
also a sensitive and specic sign of lymphedema. The presence of these factors in the history and on physical examination can help rule
out other diagnoses such as a venous thromboembolic event, heart failure, renal failure, or
venous insufciency. Of note, adult-onset primary lymphedema is rare. Lymphedema is a
chronic condition that progresses through four
stages and can be assessed on physical examination [53].
a 20%–40% difference in limb size with associated brosis and irreversible edema; (d) Stage 3 severe lymphedema with >40% limb difference, and abnormal fat
deposits (Dessources etal. 2020)
Prevention ofLymphedema
Following Inguinofemoral
Lymphadenectomy
Some data suggest there is no benet to the routine prescription of graduated compression stockings in the prevention of lymphedema after IFL
[100]. Findings from other studies, however, suggest that the use of compression stockings combined with patient education delays the onset or
even reduces the risk of lymphedema [47, 95].
31 Inguinal Lymphadenectomy, Radical Vulvectomy
335
A historical study of interest that randomized
patients with vulvar cancer with positive nodes
after radical vulvectomy and IFL to either adjuvant radiation therapy or pelvic lymph node dissection found that adjuvant radiation therapy was
associated with a decreased risk of lymphedema
and improved two-year survival rates [51]. On
the topic of radiotherapy, adjuvant radiation after
IFL increases the risk of lymphedema by way of
decreased lymphatic proliferation potential,
interstitial brosis compressing lymphatic vessels, and precipitating mechanical insufciency
of the lymphatic system [4]. Thus, avoiding adjuvant radiation unless clearly clinically indicated
can help prevent LEL. To decrease the use of
unnecessary pelvic radiation, one study demonstrated that performing minimally invasive pelvic
lymphadenectomy was an effective method to
screen for patients who do not need adjuvant
whole pelvic radiation after IFL [58].
Whenever feasible and indicated, SLN dissection without full IFL is the best method to
prevent lower extremity edema. In general, the
indication for lymph node sampling includes
any tumor greater than stage IA.Omitting full
IFL is reasonable in vulvar tumors <4cm. Full
lymphadenectomy after SLN dissection depends
on the size of the SLN metastases. In the
GROINSS-V-I study, 135 patients with positive
SLNs were identied; 115 underwent IFL with a
6% groin recurrence rate, 14 underwent radiation therapy with a 14% groin recurrence rate,
and 4 had no treatment with a 25% groin recurrence rate. Omitting IFL in patients with negative SLNs was found to be safe and was
associated with a decreased rate of LEL (1.9%
with SLN sampling alone versus 25.2% with
SLN sampling and IFL, P < 0.0001) [105].
GROINSS-V-II, a subsequent prospective phase
II trial examining radiation therapy in patients
with positive SLNs without IFL, found the risk
of groin recurrence was signicantly lower in
patients with an SLN metastasis ≤2 mm
(P=0.008). This study also found signicantly
lower rates of lymphedma in the radiotherapyonly group compared to patients who had IFL
with or without adjuvant radiation therapy [72].
Patients who underwent IFL had lymphedema
rates of 32% and 22.9% at 6 months and
12months, respectively.
Saphenous vein preservation has been shown
to be associated with less morbidity. A metaanalysis of four studies demonstrated that preservation of the saphenous vein was associated with
a decreased risk of LEL (OR: 0.24, 95% CI:
0.11–0.53), wound necrosis (OR: 0.34, 95% CI:
0.19–0.59), and acute cellulitis (OR: 0.4, 95%
CI: 0.16–0.96) [1]. In a retrospective evaluation
of patients with vulvar squamous cell carcinoma
who underwent IFL, saphenous vein preservation
was associated with reduced risk of wound cellulitis, wound breakdown, and chronic lymphedema [23]. A systematic literature review of 36
studies on IFL morbidity found that sparing the
saphenous vein decreased wound infections,
wound breakdown, cellulitis/erysipelas, and
lymphedema (Table31.2) [23, 81, 87, 110, 25].
Preservation of the fascia lata of the major
anterior thigh muscles of the femoral triangle
during IFL has also been associated with a
decreased risk of postoperative LEL. The proposed mechanism for this association is the
maintenance of the unidirectional valves of the
veins and lymphatics [40, 109]. In one study
investigating this fascia-preserving technique,
the researchers made a curvilinear incision at the
base of the femoral triangle, creating a ap
between the supercial and deep layers of the
Camper’s fascia. At the completion of nodal dissection, the ap was sutured to the fascia lata to
eliminate dead space [109]. With this technique,
the authors noted a 12% rate of lymphedema.
Skin necrosis and local infection made up 5.5%
and 2.5% of the postoperative complications in
this study, respectively, and oncological outcomes were not compromised.
Pedicled omentoplasty is another technique to
decrease the risk of LEL after IFL. This technique, which has been reported after pelvic
lymph node dissections, is thought to decrease
LEL by altering the absorption or transport of
lymph uids. The benet of pedicled omentoplasty in IFL was tested in a pilot study of four
women and three men with inguinal metastatic
lymph nodes [11]. After IFL, four of the seven
patients had mild asymptomatic lymphedema,
336
Overall ≥1
complication
C. Lam and M. M. Leitao
Short term Long term
Wound infection Wound breakdown Lymphocele Lymphedema Cellulitis/erysipelas
Table 31.2 Summary of rates of short-term and long-term complications separated by saphenous vein sparing and saphenous vein ligating techniques [81]
Study N Sparing Ligation P-value Sparing Ligation P-value Sparing Ligation P-value Sparing Ligation P-value Sparing Ligation P-value
49 0 45 <0.001 0 25 <0.02 0 0 – 11 39 <0.05 0 6 NS –
Per groin
Dardarian
2006
355 18 30 0.01 16 36 <0.001 – – 23 45 <0.001 – – –
Rouzier
2003
139 – – 13 38 0.001 10 4 NS 32 70 – 18 39 0.006 –
Zhang
2000
128 68 73 NS – – 26 32 NS 25 48 <0.01 21 41 <0.05 –
Zhang
2007
31 Inguinal Lymphadenectomy, Radical Vulvectomy
337
and the remaining three, who were noted to have
lymphedema preoperatively, had improvement in
their symptoms postoperatively. To achieve this
ap, surgeons in this study made both an abdominal and an inguinal incision, mobilized an omental ap, passed the ap deep to the inguinal
ligament through the femoral canal, and sutured
it into place. In this study, the saphenous vein was
ligated at its proximal and distal ends. One difculty that surgeons encountered with this technique was the inadequate length of the omental
ap. This technique has yet to be validated in
larger trials. Omental nodal harvest can also be
achieved via a free-ap method, which does not
require passage through the femoral canal and
eliminates concern about adequate length; however, it would require an adequately vascularized
ap with microsurgical anastomosis to vessels in
the groin [11].
Lymphovenous anastomosis (LVA) is another
technique to help prevent the development of
LEL.This approach involves simultaneously preparing an accessory branch of the femoral vein at
the time of lymphadenectomy of the groin (or
axillary vein in the case of axillary lymph node
dissection) followed by an anastomosis with one
or more afferent lymphatic vessels (Fig. 31.2).
Jørgensen et al. conducted a systematic metaanalysis of studies treating patients with prophylactic LVA following lymphadenectomy to
prevent lymphedema. In a quantitative analysis of
studies including a control group, the authors
found patients treated with prophylactic LVA had
Fig. 31.2 Lymphovenous anastomosis. (Courtesy of Dr.
Mario M.Leitao, Jr.)
a relative risk of 0.33 (95% CI: 0.19–0.56) for
developing lymphedema compared to controls
[56]. Of note, ve of these studies involved
patients with gynecologic cancer, two of which
involved patients with vulvar cancer specically.
Morotti et al. performed one of the two studies
and assessed microsurgical LVA in the prevention
of lymphedema in patients with vulvar cancer.
This study demonstrated the feasibility of LVA at
the time of IFL.LVA appears to be a promising
technique for decreasing lymphedema in highrisk patients, although more studies are needed.
Laparoendoscopic single-site surgery (LESS)
is a minimally invasive technique that has
recently been used for IFL in gynecologic oncology diseases, including vulvar and vaginal cancers. A small single-site study, which evaluated
six patients with vulvar or vaginal cancer who
underwent LESS for inguinal lymphadenectomy
from July 2018 to March 2019, demonstrated
LESS is a feasible and safe technique for the
management of these gynecologic malignancies,
with no reported postoperative complications
[108]. However, this is an extremely small series
to make denitive recommendations.
Robotic-assisted video endoscopic inguinal
lymphadenectomy (RAVEIL) is another minimally invasive technique used for IFL.The feasibility of this modality was demonstrated in a
study by Josephson etal. [57]. In a retrospective
study, reduced complication rates were noted with
RAVEIL for the management of penile carcinoma
compared with an open approach, while maintaining adequate surgical outcomes [89]. In this study,
saphenous vein preservation was more likely with
RAVEIL compared to standard- approach inguinal
lymphadenectomy. Video endoscopic inguinal
lymphadenectomy (VEIL) without robotic assistance was studied in 46 patients with vulvar cancer, and VEIL was associated with reduced
postoperative complications compared to traditional open technique for inguinal lymphadenectomy [64]. Therefore, the use of VEIL by trained
surgeons, with or without robotic assistance, may
be considered in patients with vulvar cancer to
decrease the risk of postoperative complications.
This approach, however, requires more investigation before routine adoption.
338
Management ofLymphedema
Following Inguinofemoral
Lymphadenectomy
Conservative options for the management of
lymphedema include lower extremity elevation
when at rest, compression techniques, manual
lymphatic drainage, exercise, intermittent pneumatic compression devices, and low-level laser
therapy. There are no clear data to suggest which,
if any, of these measures is most effective in the
treatment of lymphedema; although, there does
not seem to be any harm documented as a result
of these treatments [73].
Surgical management of lymphedema
includes two approaches: physiologic and ablative. Physiologic surgical options attempt to
improve lymph ow by supporting lymphatic
pathways, whereas ablative surgical options aim
to debulk lymphedematous areas and reduce
morbidity [60]. Lymphaticovenular anastomosis, also known as lymphovenous bypass, is a
physiologic surgical technique to reroute lymphatic uid into the venous system; however,
there are mixed data regarding the efcacy of
this technique (Fig. 31.3) [18, 22, 32, 52, 59].
Vascularized lymph node transfer is the preferred modality to restore lymphatic drainage in
dysfunctional lymph node basins after lymphadenectomy or radiation therapy. This technique
entails the transfer of vascularized lymph nodes
to the desired area either via free aps or in a
pedicled fashion. Although there is a rare risk of
iatrogenic lymphedema due to lymphatic disruption at the transfer site [78, 101, 106, 107], most
studies have demonstrated improvement in
lymphedema symptoms and quality of life [19,
66, 74, 83]. For advanced-stage chronic lymph-
edema, ablative procedures such as the Charles
procedure, which involves the removal of skin
and subcutaneous tissue followed by skin grafts,
may restore functional decits and provide relief
in debilitating lymphedema. Suction-assisted
lipectomy can be useful in patients who do not
have signicant pitting edema and who are not
candidates for other surgical techniques.
Although this method is limited, good patient
satisfaction has been reported with suctionassisted lipectomy [13, 14].
C. Lam and M. M. Leitao
Fig. 31.3 Lymphovenous bypass. (Courtesy of Dr. Mario
M.Leitao, Jr.)
Background ofInfectious Morbidity
Following Radical Vulvectomy
andInguinofemoral
Lymphadenectomy
Vulvectomy has long been known to have high
rates of postoperative complications due to several host factors, including the specic microbial
ora of the genital tract and its surrounding structures, decreased host immunity due to malignancy and other potential comorbidities, prior
chemotherapy or radiation in the area, and difculty of wound care at the surgery site. One study
noted a wound infection rate of 7%, and the most
common pathogens isolated from wound sites
were Pseudomonas aeruginosa, Enterococcus,
and Escherichia coli [29].
Although SLN mapping is now an accepted
standard for vulvar cancer staging, there are still
instances when full IFL is warranted, particularly
in patients with vulvar tumors ≥4cm or multifo-
31 Inguinal Lymphadenectomy, Radical Vulvectomy
339
cal disease. IFL performed for the purpose of
sampling enlarged groin lymph nodes is associated with a complication rate as high as 60% [40,
98], with the most common complications being
lymphorrea, seroma, infection, and wound breakdown. Some suggested predictors of postoperative complications include number of lymph
nodes removed, pathologically positive nodes,
patient age, and disease stage [36]. Groin
dissection is associated with a high risk of infection due to the inherent moisture in the area and
the risk of contamination. Rates of wound infection after groin surgery range from 6% to 29%
[10]. Wound infection invariably increases the
risk of wound breakdown. Gaarenstroom et al.
[33] examined modied radical vulvectomy with
IFL through separate incisions and found the
incidence of wound breakdown was up to 39%,
with or without infection [33]. The next sections
will cover methods identied in the literature to
recognize, prevent, and manage the complications of wound infection.
Recognition ofInfectious Morbidity
Following Radical Vulvectomy
andInguinofemoral
Lymphadenectomy
Clinical signs of infection, including leukocytosis and fever, should be used in conjunction with
physical examination ndings including erythema, edema/induration, and/or purulent discharge. Wound breakdown can also be present.
Necrotizing infection, which will usually present
with pain out of proportion to physical examination ndings, crepitus on palpation, skin discoloration, and imaging ndings suggestive of gas in
the area of interest, is important to rule out.
Prevention ofInfectious Morbidity
Following Radical Vulvectomy
andInguinofemoral
Lymphadenectomy
As mentioned previously, the GROINSS-V-I
study demonstrated a signicantly decreased risk
of postoperative morbidity with SLN sampling
alone versus SLN sampling with IFL, with rates
of wound breakdown of 11.7% versus 34.0%,
respectively (P< 0.0001), and rates of cellulitis
of 4.5% versus 21.3%, respectively (P<0.0001)
[105].
Preoperative preparation of the skin and
vagina with povidine-iodine or chlorhexidine
gluconate is universally recommended to prevent
infection [5], and should be performed for
patients who undergo radical vulvectomy and/or
IFL. A randomized controlled trial comparing the
use of chlorhexidine gluconate and iodine for
vaginal preparation prior to hysterectomy in 85
patients demonstrated decreased vaginal bacteria
count in patients who underwent chlorhexidine
preparation; although, no surgical site infections
were identied in either group [46]. In a propensity score-matched analysis, however, povidineiodine was shown to be preferable to chlorhexidine
in vaginal preparation before hysterectomy due
to lower rates of infection and fewer emergency
department visits [97]. Thus, the choice of preparation solution can be left to the surgeon’s preference due to the limited data supporting one over
the other.
Aside from open versus endoscopic modalities, there is clear variation in actual surgical
technique for groin surgery. One randomized
controlled trial compared postoperative complication rate with the use of LigaSure technology
versus conventional (sharp/diathermia) technique
and found the estimated incidence of ≥1 postoperative complications was 29% after LigaSure
versus 70% after conventional inguinal lymphadenectomy (P < 0.001) [80]. Creating separate
incisions for radical vulvectomy and lymphadenectomy has been shown to decrease risk of
infectious morbidity in several studies [29, 41].
The use of groin drains has been investigated
in several studies. One retrospective cohort study
by Pontre etal. showed the use of groin drains
signicantly reduced the incidence of postoperative groin cellulitis (8.7% versus 25.4%,
P=0.039) [79]. Duration of drain use does not
seem to have an effect on the development of
postoperative complications [37]. In a Dutch
nationwide prospective study by Pouwer etal.,
using volume-based standards for drain removal
was found to be superior to time-based removal
340
C. Lam and M. M. Leitao
(removal of drain on postoperative day ve) in
decreasing complication rates (46% versus 75%,
respectively, P = 0.006) [82]. Of note, no randomized controlled trials have compared surgical
outcomes of inguinal lymphadenectomy with and
without use of drains.
In a prospective clinical study examining postoperative outcomes after radical lymphadenectomy or SLN procedure, Asciutto etal. employed
negative pressure wound therapy (NPWT) in conjunction with groin drains [6]. Surgical site complications were identied in 11 of the 20 patients
(55%) who underwent NPWT; one patient suffered a wound rupture, six patients developed
lymphoceles, and four patients had a surgical site
infection. Although no statistical tests were performed, the use of NPWT in this small cohort was
thought to reduce the severity of surgical site
complications after inguinal lymphadenectomy.
The efcacy of NPWT was evaluated in a metaanalysis of studies looking at its use in various
other surgery types (orthopedic, abdominal,
colorectal, and obstetric) and was associated with
a signicant reduction in surgical site infection,
wound dehiscence, and length of stay [99].
Modest weight loss preoperatively can potentially decrease the risk of development of at least
one complication. In a study of 204 patients with
melanoma, the risk of developing at least one
complication for all patients who underwent
regional lymph node dissection of the neck,
axilla, and groin was increased in obese patients
(P=0.05) [104].
It is common to recommend frequent sitz baths
or loose-tting underwear postoperatively, but
there are limited data to support these practices
for the prevention of infection and wound breakdown after vulvectomy in patients with gynecologic cancer. One randomized controlled trial
examining sitz baths after episiotomy did not nd
a statistically signicant decrease in the rate of
wound breakdown [70]. Prospective data are still
needed to optimize postoperative vulvar hygiene
and wound care regimens in patients with gynecologic cancers. In addition to the above measures,
some clinicians prescribe sitting restrictions to
prevent direct pressure on the incisional area for
four to six weeks postoperatively. Inatable
donut-like devices or soft pillows provide support
and maintain quality of life for patients while following sitting restrictions during recovery.
However, no data are available that specically
address the efcacy of sitting restrictions in preventing wound complications after vulvectomy.
Management ofInfectious
Morbidity Following Radical
Vulvectomy andInguinofemoral
Lymphadenectomy
Infection should be managed with antibiotics,
either parenteral or oral, and the antibiotic regimen should be tailored based on the clinician’s
judgement of infection severity. Wound culture
should be obtained if applicable to the clinical
scenario. Antibiotics should be started empirically and tailored to wound culture results if
obtained. In the setting of infection, there may be
clinical utility to reopen the incision if the wound
has not already opened on its own. The incision
should then be allowed to close by secondary
intention, whether with wet-to-dry dressing or
NPWT, whichever is feasible. NPWT has the
benet of evacuating wound uid, stimulating
granulation tissue formation, and decreasing bacterial colonization of the wound; although, in one
retrospective study of the use of vacuum-assisted
closure in complex wound failures, patients with
gynecologic cancer complained of pain with
wound dressing changes [94]. In this study, 96%
of patients had complete wound healing.
Extensive surgical debridement is the mainstay
of treatment for necrotizing soft-tissue infections
of the vulva [21]. If this is suspected, early and
aggressive surgical resection is critical to minimizing morbidity and mortality.
Background ofFunctional
Impairments After Radical
Vulvectomy
Vulvectomy has the potential to result in signicant anatomic distortion, leading to a number of functional impairments, including
31 Inguinal Lymphadenectomy, Radical Vulvectomy
341
difculties with micturition, defecation, and
sexual activity [48].
In one questionnaire study, fecal incontinence
was reported in 43% of survivors of gynecologic
cancer [90]; however, rates of fecal incontinence
in patients who underwent vulvectomy specically were not reported.
Various forms of sexual dysfunction have
been reported after a vulvectomy, including sexual aversion disorder, hypoactive sexual disorder,
and arousal disorder. Factors associated with
posttreatment sexual dysfunction in patients who
underwent surgical treatment for vulvar cancer
include increased age, poor overall well-being,
history of depression or anxiety, and excision
size of vulvar malignancy [2]. Compared to
healthy controls, patients with vulvar cancer are
at increased risk for sexual dysfunction, both
before and after surgical excision [3]. Extent of
surgery or type of vulvectomy has not been found
to be correlated with the degree of sexual dysfunction present postoperatively [38].
Pelvic Organ Prolapse Quantication system
(POP-Q) to assess for pelvic organ prolapse contributing to urinary symptoms. Urinary tract
infection should be ruled out in patients presenting with new-onset urinary incontinence postoperatively. Anatomic distortions, particularly in
patients who underwent urethrectomy as part of
radical vulvar surgery, can be identied on physical examination as contributing factors to urinary
incontinence; these patients can present with
total incontinence (Fig.31.4).
When a patient presents with sexual dysfunction, it is important to screen for psychosocial
factors that may be contributing factors, including depression and relational discord. Physical
examination can elucidate whether there is an
anatomical aberration related to vulvar surgery,
including introital stenosis or clitoral distortion
(Fig.31.4).
Once again, performing a thorough history
and physical examination are crucial to diagnosing fecal incontinence. Fistula can be an etiology
Recognition ofFunctional
Impairments After Radical
Vulvectomy
Functional impairments can be diagnosed based
on patient-reported symptoms postoperatively.
These symptoms can present immediately or
even one year after primary surgery. According to
a questionnaire-based study, only 40% of survivors of gynecologic cancer reported having been
asked about urinary/fecal incontinence or sexual
function by their oncologist [90], which highlights the importance of obtaining a thorough history and physical examination to recognize and
treat these functional impairments.
Urinary incontinence is very common in postmenopausal patients, with or without radical vulvectomy. Urinary incontinence should be
separated by type, namely, urge, stress, or mixed
incontinence. Because treatment will depend on
the type of incontinence present, it is important to
take a thorough history and perform a detailed
physical examination, including specic tests
such as the Q-tip test for urethral mobility and the
Fig. 31.4 Introital stenosis with urethral hooding and
fecal incontinence after radical vulvectomy. (Courtesy of
Dr. Mitchel Hoffman)